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lunes, 4 de mayo de 2020

Refractory Hypoxemia & ARDS

"Transport of the ARDS patient is fraught with risk. These patients are at high risk of decompensation, which can be disastrous in the back of an ambulance or helicopter. The primary goal for critical care transport teams should be safe arrival of both the crew and patient to their destination. As such, if patients are achieving an adequate oxygen saturation at the referring facility, the better part of valor is to continue the current course, even if the crew believes that ventilator settings are suboptimal. If ventilator changes need to be made due to inadequate oxygenation, ventilation, or other factors, strong consideration should be given to LPV settings. Of note, ventilator settings utilized in an emergency department setting have been strongly correlated with the settings used in the ICU, and changes designed to encourage adherence to LPV have been associated with reduced incidence of ARDS and even mortality (38). It is reasonable to assume that this therapeutic momentum may apply in the inter-facility setting. Any ventilator changes should be made prior to loading the patient to ensure a period of stability and to ensure the availability of extra staff if decompensation does occur. NMB can be considered for patient who remain dyssynchronous with the ventilator despite appropriate analgosedation. Adjunct therapies, including APRV or proning, should only be considered by appropriately experienced teams after rigorous preparation, including high-fidelity simulation. Given the increasing use of ECMO in the United States, it is reasonable to assume that transport of these patients will become increasingly common. It is imperative that critical care transport teams be familiar with the data informing management of these patients, to ensure that we continue to deliver definitive care outside the walls of the hospital."